Rammelt S, Zwipp H, Mittlmeier T
Klinik und Poliklinik für Unfall- und Wiederherstellungsschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
Oper Orthop Traumatol. 2013 Jun;25(3):273-91; quiz 291-3. doi: 10.1007/s00064-013-0235-6.
Early reduction of the dislocation and anatomic reconstruction of axial alignment, ankle mortise and articular congruity with special focus on syndesmotic stability.
Fracture-dislocations resulting from pronation injuries to the ankle with a highly incongruent and unstable mortise and either considerable internal pressure on the soft tissues by the displaced fragments or open soft tissue damage.
General contraindications to surgery: closed reduction and cast immobilization or external fixation.
Early preoperative closed reduction of complete dislocations is achieved through longitudinal traction and movements contrary to the original fracture mechanism. A cast or joint-spanning external fixator is applied temporarily. Ideally, definite anatomic reduction of the posterior tibial fragment, the distal fibula and medial malleolus and stable internal fixation is achieved within the first hours after the injury. Congruity of the ankle mortise and syndesmotic stability is controlled intraoperatively and a syndesmotic screw is inserted if necessary. In these cases, the correct positioning of the distal fibula within the tibial incisura is verified with three-dimensional fluoroscopy or postoperative computed tomography scanning.
Early range of motion exercises of the ankle and subtalar joints are initiated the second postoperative day or after soft tissue consolidation and removal of the external fixation. Patients are mobilized with partial weight bearing (20 kg) in a cast or special boot for 6 weeks postoperatively. The syndesmotic screw is then removed in most cases and weight-bearing is rapidly increased.
The presence of a dislocation at the time of injury represents a negative prognostic factor in malleolar fractures. Higher rates of posttraumatic arthritis are also observed with trimalleolar fracures, especially fractures of the posterior tibial rim, cartilage damage, and syndesmotic disruption. Irrespective of the fracture classsification, good to excellent results can be obtained in 75-89% of cases with anatomic reconstruction of the ankle mortise and the articular surfaces. Proper reduction of the distal fibula into the tibial incisura is of utmost importance in cases of frank syndesmotic diastasis.
早期复位脱位并对轴向对线、踝关节 mortise 和关节一致性进行解剖重建，特别关注下胫腓联合稳定性。
因踝关节旋前损伤导致的骨折脱位，伴有高度不一致且不稳定的 mortise，以及移位骨折块对软组织产生相当大的内部压力或开放性软组织损伤。
手术的一般禁忌症：闭合复位及石膏固定或外固定。
通过纵向牵引和与原始骨折机制相反的动作，早期对完全脱位进行术前闭合复位。临时应用石膏或跨关节外固定器。理想情况下，在受伤后的最初数小时内实现胫骨后骨折块、腓骨远端和内踝的明确解剖复位及稳定的内固定。术中控制踝关节 mortise 的一致性和下胫腓联合稳定性，必要时插入下胫腓联合螺钉。在这些病例中，通过三维荧光透视或术后计算机断层扫描验证腓骨远端在胫骨切迹内的正确位置。
术后第二天或软组织愈合及去除外固定后开始早期踝关节和距下关节的活动度锻炼。术后 6 周，患者在石膏或特制靴中部分负重（20 千克）活动。大多数情况下，随后取出下胫腓联合螺钉并迅速增加负重。
损伤时存在脱位是踝关节骨折的不良预后因素。三踝骨折，尤其是胫骨后缘骨折、软骨损伤和下胫腓联合破坏，创伤后关节炎的发生率也较高。无论骨折分类如何，踝关节 mortise 和关节面解剖重建的病例中，75 - 89%可获得良好至优秀的结果。对于明显的下胫腓联合分离病例，将腓骨远端正确复位至胫骨切迹至关重要。
